Public Services and Procurement Canada
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Provision of the information requested on this document is required under paragraphs 13(1)(b) and (d) and section 28 of the Public Service Superannuation Act (PSSA) and sections 42.1, 43.2 and 43.3 of the PSSA Regulations. The information will be used for the purpose of determining entitlement to a pension for medical reason. The personal information is described in Personal Information Banks PWGSC PCE 702 and HCan PCE 701/703, and will only be used and disclosed in accordance with the provisions of the Privacy Act. Under this act, the individual to whom the information pertains has the right to request access to and correction of the personal information, if erroneous or incomplete. The records will be retained by the department for two years following the last administrative action, and then destroyed.
This form must be completed electronically. If not possible, please use dark ink and capital letters.
I understand that this application is initiated for medical retirement.
A copy of my work description is attached.
The details of the medical examination should be entered on form HC/SC 3312E. Forms PWGSC-TPSGC 2012 and HC/SC 3312E should then be sent to the appropriate Medical Services Branch office, located at:
Please do not send form HC/SC 3312E or confidential medical information to any non-medical government office.
I, the undersigned, duly qualified medical practitioner, certify that I have made a detailed examination of the above-named plan member and that in my opinion the said individual:
The original of form PWGSC-TPSGC 2012 should be forwarded to the Public Service Pension Centre - Mail Facility, 150 Dion Blvd, PO Box 8000, Matane QC G4W 4T6. Complete number 1 or 2 below.
A copy of the completed form should be sent to the employer indicated in Section A.
Where disability commenced on or after January 1, 1996 (refer to definition 1 on the INSTRUCTIONS page)
Where disability commenced before January 1, 1996 (refer to definition 2 on the INSTRUCTIONS page)
PWGSC-TPSGC 2012 (12/2009)